2nd Level Appeal Approval.

Today was a good day in my journey towards getting my underbite fixed. 

Many of you know that I started this process in October of 2012 when my then new dentist encouraged me to start the journey of looking into getting my underbite fixed with orthognathic surgery.

Here are some links to my previous posts detailing this if you're interested:

Post 1: My New Metal Mouth

Post 2: My First Surgery

We originally started to plan the surgery for December of 2014, but that didn't work our for several reasons.

Long story short...Sarah changed jobs in January. Leaving her last job in December meant our health insurance left too. We had pre-approvals for everything with the surgery with the old insurance company and we were hopeful things would be good with the new insurance company, that we got through my work.

In January, my surgeon's office called the insurance company to check if all the surgery stuff (including pre and post op) were covered billing codes. They said yes those are covered codes, but you will need to get a pre-authorization. So, we planned to have the surgery the first week of May 2015.

We were all systems go at this point, or so we thought...

In February, the surgeon's office put in the authorization request, I got FMLA and short term disability approval from work, and we had everything scheduled.

Then one March afternoon, about a month after we requested the authorization, I got the mail on my way home like I do most days. I don't remember the exact day, but on this day there was an envelope from my insurance company. I opened the envelope to find a letter from my insurance company saying the authorization for a pre-surgery CT scan and any surgery was denied due to an exclusion for dental procedures in my insurance policy.

We were in shock. It seemed very odd after being told the billing codes were covered, and having many medical professionals tell me this surgery was "medically necessary" for me, to get a denial of benefits.

The bad news: a denial; the good news: you can appeal the decision.

So we appealed. My surgeon's office put together documentation proving the medical necessity, including letters from the surgeon and my orthodontists. We felt good about this appeal and thought we had a good chance based on all the evidence we provided. The appeal paper work was faxed the first week of April 2015.

Due to some weird appeal authorization (we were told we did not need) required for the surgeon's office to appeal on my behalf, the appeal did not get looked at until May 27th.

The first level appeal panel, upheld the initial decision citing the same vague dental exclusion, which in my opinion likened my jaw surgery to getting a tooth pulled or getting x-rays.

At this point we were unsure what to do, but the paper work said we could do a 2nd Level Appeal. So that's what we did. My surgeon's office gathered more information and evidence and sent off the 2nd level appeal, the last week of June.

After a lot of waiting, considering, and praying, we started looking into options to have the surgery without using the insurance. Sarah and I looked at loans, borrowing against her 401K, starting a Go Fund Me Page, etc.

On August 14, I received an email from a Grievances and Appeals Analyst named John from my insurance company, inviting me to attend a meeting on September 2 to state my case for why I believe the surgery should be covered. I did not get such an invitation for the 1st level appeal.

This bring us to today. This morning September 2, 2015, Sarah & I attended this 2nd level appeal panel meeting. We were almost late due to the wonderful Denver traffic. Thanks Denver!

When we got to the insurance building we were met by John. He gave us an overview of what would happen in the meeting and told us that they would make a decision on the appeal today after our meeting.

The meeting lasted about 20 minutes for us. The meeting facilitator introduced the three panel members who would be voting and explained the agenda to Sarah and I. Then they had the Analyst John, give a summary of what we were asking in the appeal to the panel.

At this point the facilitator gave me the floor and allowed me to present my case for why I believed the surgery was medically necessary. Sarah added a few points as well!

Next, the facilitator asked the panel if they had any questions for us. They asked a few questions. Then our part was done.

We thanked them for allowing us to be there and for listening to our case. John walked us out, and now it was time for them to review all the info, deliberate, and most importantly, vote.

We were really unsure what to expect from this appeal meeting, but it was all rather cordial and pleasant. When we were leaving John said to me, "You did a really good job!" Sarah and I took that as a sign to be cautiously optimistic.

As we were leaving, John told us he would send out paperwork later this week with the panel's decision, but I asked if he would email me today, so I would know and not have to wait for days for an answer.

Sarah and I got back to our house in Colorado Springs from Denver and there was an email waiting from John.

The verdict was in...we checked nervously...APPROVED!

We were ecstatic! I jumped around the house like a little kid at the excitement of Christmas shouting, "Praise the LORD!" 

So, now we will start the process of getting the surgery planned again, this time with insurance approval!

I am so thankful for the many family members and friends that have been praying for this. The past eights months have been hard dealing with this. Today was a huge relief and blessing!

I'll will keep this blog updated with surgery details, so be looking for that.

As always, thanks for taking the time to read my blog. May God richly bless you and your family!

My New Metal Mouth...

So...today I got braces. Well, actually I got some of the brackets to hold the wires and some separators to make space for some bands to hold brackets on my molars last week. But today, I got the rest of the brackets and the wires in the brackets.

So, now I'm officially on a several year journey to get my jaw fixed. In a year or so, I will need an oral surgery in which they cut and rearrange my jaw to a proper bite. My top jaw will be moved forward, and my bottom jaw back, and my jaw will be wired shut for six weeks after the surgery. Sounds like fun doesn't it?

But before we go on we need to go back in time...

As a kid, most of my adult teeth grew in crooked. In fact, one grew in almost sideways. My bottom jaw began to grow faster than my top jaw, so I developed an under-bite. At the advice of the dentist, my parents got me braces. Thanks Mom and Dad!

I wore braces for about seven years of my childhood, spanning from elementary to high school. They tried to fix my under-bite with some appliances and the braces, but it didn't really work. We were told that surgery would be the only way to fix it, but I didn't have to do that.

My under-bite was pretty minor at that point. But what we didn't know, was that not getting surgery assumed I was done growing, and that my under-bite didn't get worse. As you can probably guess, I continued to grow through college, and so did my under-bite. My top jaw didn't grow enough and my bottom jaw grew too much.

From then until now I had dentists ask if I had ever seen an orthodontist, and ask if my jaw hurt and such. My last dentist asked me to consult with an orthodontist in his office, so I did. He told me what I had heard since getting my braces off as a kid, that it would take surgery to fix my bite, but if I don't have pain and I can chew, it's not a big deal.

So, I planned to go through life with my under-bite. Besides, I survived the teasing of kids in junior high, high school, and college without becoming a mass murderer, and I learned how to deal with eating problems. You can imagine how fun eating an apple or corn on the cob is for me.

On October 10, 2012 I got new dentist, and seeing him for the first time changed everything.

For the first time in my life, this new dentist explained that I needed to get my bite fixed, or I might not have any teeth in 10 years, and they can't make dentures for my bite. He also informed me that my bite was destroying my teeth and that's why I had so many crowns, fillings, and root canals, despite my good oral hygiene. At least my gums are really healthy! 

On top of that, he told me the stress from my bite can cause all kinds of bone problems in my jaw that could lead to all kinds of problems and surgeries. I was shocked. I told him how I had been on other consults, and they always acted like it was no big deal. To which he said they probably didn't want to deal with an under-bite as severe as mine, because it's hard work. I had never had a dentist be so candid with me before, and more than that, he seemed to actually care.

So my new dentist asked me to go see another orthodontist in town who was one of the best in the country with helping people fix their under-bites. So I did.

The orthodontist said I definitely need to have this surgery, and confirmed everything my dentist said. So, after some fancy x-rays, bite impressions/ models, oral examinations, a treatment plan, a consult with a periodontist, a consult with an oral surgeon, a revised treatment plan, and two more office visits to the orthodontist, we are back to today. Me with a mouth full of metal and sore teeth.

I'm not sure what the point of this blog is other than to inform people who might care. Well, and to say that braces suck, but being an adult with braces really sucks! I would really covet your prayers as I continue on this adventure, because as you might guess it's not cheap and we are not sure where we will get the money for the oral surgery yet (that's the most expensive part and only partially covered by our medical insurance).

If you took the time to read this blog, thanks for caring about me! I pray that God blesses you and your family greatly!

Oh, and just for fun here's a picture of my new metal mouth:

Hey homies, check out my new grillz!!

Stange Experience

So I had a pretty strange experience yesterday (9/16/2011), I went to see an Orthopedic Surgeon for the first time in my life. Let me back up...

I have played baseball ever since I can remember. After High School I started playing men's competitive slow pitch softball. I had a minor right shoulder injury my sophomore year of High School, but recovered with physical therapy. Since then my shoulder has been fine.

In April 2011, I played in a softball tournament in Aurora, CO. We played about 5 games that day and after my right shoulder was sore. It slowly got worse, but I still had good range of motion, and strength, so like any guy does I figured it would just get better and there was no reason to go see the doctor.

A month later (May 2011), it was still hurting so I went to my doctor. He thought it was just swelling and gave me some anti-inflmatory pills. They didn't help. But life got busy, I took a season off softball, went to South Africa, and my shoulder never really stopped hurting.

I went back to my doctor in August 2011. He took some X-Rays, couldn't see anything there, so he referred me to the Orthopedic Surgeon. Now we are all caught up. Recap, hurt my arm on April 16, and I'm finally on the road to recovery on September 16, five months later. I know typical guy.

The Orthopedic Surgeon said, "The good news is there is no arthritis or bone spurs, but the bad news is that I have Tendinitis (swelling/ inflammation) in my shoulder and a Slap Tear."

So to help with the tendinitis I got a Cortisone Shot in my right shoulder, that was the afore mentioned strange experience. Most of my issues are in the front of my shoulder, but they administer the shot from the back of your shoulder. The needle was bigger than any other shot I have ever had. Thankfully, they spray you with a numbing medication to help with pain and the shot itself had some numbing medication with it. However, feeling a large needle moving around in your shoulder and the pressure that comes with it was, well, a strange feeling.

I also have to do 6-8 weeks of physical therapy which I start on September 20. I have a 50/ 50 chance of that healing my shoulder, or I will need surgery to repair the SLAP Tear. I have never had or needed a surgery before, so that was also a strange thing to hear.

Thought it would be fun to share this experience with those who care about me. Here's to hoping and praying that the physical therapy will heal my right shoulder. And as always thanks for reading my blog.

Love God & Live Free!

PS: Not looking for sympathy, but prayers are appreciated!